Comprehensive Psychiatric Evaluation Template Nursing Essay Example

Comprehensive Psychiatric Evaluation Template Nursing Essay Example

Subjective:

Name: Mrs. Leslie Tilman,  Gender: Female, Age : 32 years

CC (chief complaint):I cant sleep much but that is to be expected.

HPI: Mrs Tilman presented to the clinic after her husband became concerned about her behavior after delivering her baby two months ago. The patient presents with insomnia and reports having difficulties faling asleep after waking because the baby cries a lot.She also reports feeling terrible and has gained considerable weight, getting upset easily,and yelling  lot. She also cries a a lot an has lost interest in things that used to give her pleasure like writing since she hates interruptions but knows the baby is going to interrupt her.She has also lost her sex drive.(Comprehensive Psychiatric Evaluation Template Nursing Essay Example)

Comprehensive Psychiatric Evaluation Template Nursing Essay Example
Comprehensive Psychiatric Evaluation Template Nursing Essay Example 1

Past Psychiatric History:

  • General Statement: an unremarkable psychiatric history  as she has not had mental check before.
  • Caregivers (if applicable): The husband is extremely worried about her behavior since she got a child two months ago
  • Hospitalizations: No previous psychiatric hospitalizations(Comprehensive Psychiatric Evaluation Template Nursing Essay Example)
  • Medication trials: No medications for psychiatric illness or condition
  • Psychotherapy or Previous Psychiatric Diagnosis: Negative for history of psychiatric diagnosis

Substance Current Use and History:

Denied any drugs or alcohol use

Family Psychiatric/Substance Use History:

Uncle was opioid user, and commited suicide suicide through a gunshot wound(GSW)

Psychosocial History:

Grew up with both parents, onesister in Omaha NE. Currently married is a stay at home on maternity leave after working in retail for 5 years. She graduated with Bachelors in Physics. Previousworked in research science and high school teacher for 5 years before giving birth.(Comprehensive Psychiatric Evaluation Template Nursing Essay Example)

Negative for legal history

Medical History: History of hypertension

  • Current Medications: Labetalol 100mg twice daily but admits missing doses  due to forgetting
  • Allergies:codeine
  • Reproductive Hx:12 years age at menarche, reports  normal menstrual patern in terms of cycle lenth, duration flow, amount of flow  but is not having periods as she is breastfeeding. She is not on the pill. Other reproductive history is unremarkable

ROS:

  • GENERAL: T-97.6 P 97 R 22 BP 149/98 Ht 5’3 Wt 245lbs BMI 43.4 Denies fever or chills Reports weight gain after pregnancy
  • HEENT: Denies head injury, denies diplopia or blurred vision or any changes in vision.Denies pain  or loss of haring, in the ears, reports no discharge.No nasal congestrion ordischarge. Denies throat or neck pain, denies difficulty swallowing  no hoarseness.(Comprehensive Psychiatric Evaluation Template Nursing Essay Example)
  • SKIN: No rashes or prutis, no changes of coloration or jaundice
  • CARDIOVASCULAR: No chest pain, no orthopnea, or paroxysmal nocturnal
  • RESPIRATORY: No dypnea ho egophony, breath sounds presents and clear bilsaterraly on auscultation
  • GASTROINTESTINAL: No mass or hernia observed. On auscultation bowel sounds present  in all four quadrants. Abdomen is soft and non- tender
  • GENITOURINARY: Denieshematuria, denies difficulty starting or stoping stream of urine
  • NEUROLOGICAL: headache , denies history of tremors or seizures
  • MUSCULOSKELETAL:  Denies hearing snapping or clicking sounds, denies falls or  pain
  • HEMATOLOGIC: No knowln blood or clotting disorders
  • LYMPHATICS: No lymphadenopathy(Comprehensive Psychiatric Evaluation Template Nursing Essay Example)
  • ENDOCRINOLOGIC:  No known diabetes or thyroid condition
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Objective:

Physical exam: if applicable

Mrs Tilman appears distracted, overweight and is irritable

Diagnostic results:

Urine drug screen- negative for cocaine

Random blood sugar test A1C test below 5.7% and glucose tolerancetest 139mg/dL

Thyroid blood test TSH range was 3.6 mIU/mL

Assessment:

Mental Status Examination: Level of consciousness normal patient able to respond to stimuli as individuals without neulogical abnormality.

Concentration is lowered, guilt is present, appetitie increased( evidenced by weight gain) sleep disturbance, psychomotor agitation making hr become upset easily, death or suicidal ideation but not acted upon, interest in writing decreased, energy to energy in weight reducing exercisesdecreased( ie C GASP DIE) significant for depression(Comprehensive Psychiatric Evaluation Template Nursing Essay Example)

Differential Diagnoses:

  1. Depressive Disorder

Mrs Tilby presents with symptoms significant for major depressive disorder. MDD is considered because She exhibits several symptoms that comprise the mandatory five or more of the DSM-5 Criteria for Major Depressive Disorder(Park& Zarate, 2019) lasting over two weeks. These symptoms include having a depressed mood most of the day as reported in the subjective information she gives, like feeling sad and hopeless or the observations others make like she appears tearful. The patient also diminished interest and pleasure in activities that used to give her pleasure before. She also reports not having the sex drive and repulses intimate advances by her husband. These include writing which she admits she would do but cannot do nowadays since the baby is bound to interrupt her. The third symptom is that she has trouble sleeping, and even when baby Jesica cries, she wakes up and has difficulties falling asleep again. She also reports weight gain immediately after falling pregnant, and besides psychomotor agitation, she has feelings of guilt. Suicidal ideation, although not acted upon, also presents itself amongst others.(Comprehensive Psychiatric Evaluation Template Nursing Essay Example)

  • Postpartum depression
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The woman has several symptoms of post Partum depression. These include mood swings, sadness, irritability, crying, trouble sleeping, and feeling overwhelmed. Had they lasted for a few days, they would have passed for baby blues. However, that has continued well into the second month since delivery makes postpartum depression a strong option. The symptoms develop within the first few weeks of giving birth but could have started before birth. In addition to the baby blue symptoms, the patient fears she is not a good mother, feels guilt, amongst others(Batt et al., 2020). Be that as it may, the woman admits the baby did not trigger her disinterest in sex is coming into the picture and admits that even before the birth, her social life was non –existent. This admission means that withdrawing from family and friends had happened long before Jessica’s birth, probably even before her conception. The duration of the symptoms and their onset should help rule out postpartum, as do the absence of organic causes since no other illness is present. The same criteria should rule out physiological causes like an overactive thyroid gland to blood sugar imbalances.(Comprehensive Psychiatric Evaluation Template Nursing Essay Example)

  • Side effects of skipping the prescribed antihypertensive drugs

Kessing et al. (2020) note that depression could be a side effect of nonadherence to prescribed antihypertensive drugs. The patient admits to skipping due to forgetfulness sometimes. This nonadherence would, besides causing depression, means the woman’s blood pressure is poorly controlled, but this is not the case here(Jani et al., 2016). As such, the manifesting depression could be caused by skipping the medication prescribed.(Comprehensive Psychiatric Evaluation Template Nursing Essay Example)

Comprehensive Psychiatric Evaluation Template Nursing Essay Example
Comprehensive Psychiatric Evaluation Template Nursing Essay Example 2

Reflections

 Psychiatric and mental health nurse specialists are aware that depression is a condition that disables the individual at the social and physical level related to poor self-care, increased mortality, and risk of suicide, and adverse medical outcomes. One is bound to experience an ethical dilemma about self-management that involves training, skill acquisition, and therapeutic intervents through which patients diagnosed with depression are taught how to care for themselves and manage their own lives and illnesses. Bipeta(2019) notes that the Mental Health Care Act 2017) explicitly outlines patients’ rights diagnosed with mental illness. That means that I would have to factor in these rights and translate them into ethics of psychiatric care concerning respect for autonomy, the principle of non-maleficence, beneficence, and justice. Other ethical issues to consider would be boundary violations of informed consent and confidentiality. In the event of an ethical dilemma, I would urge the community healthcare system to build commitment and trust. These attributes would help increase the level of reflections and ethical discussions in the community setting, especially when caring for depressed mothers taking care of their infants.(Comprehensive Psychiatric Evaluation Template Nursing Essay Example)

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References

Batt, M. M., Duffy, K. A., Novick, A. M., Metcalf, C. A., & Epperson, C. N. (2020). Is postpartum depression different from depression occurring outside of the perinatal period? A review of the evidence. Focus18(2), 106-119.(Comprehensive Psychiatric Evaluation Template Nursing Essay Example)

Bipeta, R. (2019). Legal and ethical aspects of mental health care.(Comprehensive Psychiatric Evaluation Template Nursing Essay Example)

Jani, B. D., Cavanagh, J., Barry, S. J., Der, G., Sattar, N., & Mair, F. S. (2016). Relationship between blood pressure values, depressive symptoms, and cardiovascular outcomes in patients with cardiometabolic disease. The Journal of Clinical Hypertension18(10), 1027-1035.(Comprehensive Psychiatric Evaluation Template Nursing Essay Example)

Kessing, L. V., Rytgaard, H. C., Ekstrøm, C. T., Torp-Pedersen, C., Berk, M., & Gerds, T. A. (2020). Antihypertensive drugs and risk of depression: A nationwide population-based study. Hypertension76(4), 1263-1279.(Comprehensive Psychiatric Evaluation Template Nursing Essay Example)

Park, L. T., & Zarate Jr, C. A. (2019). Depression in the primary care setting. New England Journal of Medicine380(6), 559-568.(Comprehensive Psychiatric Evaluation Template Nursing Essay Example)

https://www.ncbi.nlm.nih.gov/

Comprehensive Psychiatric Evaluation Template Nursing Essay Example
Comprehensive Psychiatric Evaluation Template Nursing Essay Example 3

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